Tongue-Tie and Lip-Tie

Tongue and lip-tie are common causes of nipple pain, uneven breast drainage, slow weight gain and low milk supply. Many physicians do not properly assess for tongue or lip-tie or recognize their impact on the breastfeeding relationship, leaving babies vulnerable to early weaning.

Image credit: Qole Pejorian on Flickr

This photograph shows a very obvious tongue-tie and visible frenulum (the bit of tissue holding down the tongue) but not all restrictions are this obvious. Some restrictive frenulums attach further back on the tongue. Some are even buried under the floor of the mouth, causing the tongue to appear, “short.” The only visible indication may be that the floor of the mouth rises when baby lifts his tongue or the tongue stays flat or doesn’t rise to the palate when baby cries. Sometimes the sides of the tongue will rise but the center of the tongue will stay on the floor of the mouth. Even if a baby can reach his or her tongue past the gums or lips, there may still be a tight frenulum restricting baby’s ability to breastfeed effectively.

Ultrasound studies have shown that the tongue movements used by tongue-tied babies are qualitatively different from those used by by babies who are not tongue-tied. These movements are not as effective at removing milk from the breast and can cause significant pain and nipple damage. In these studies, tongue-tied babies also did not draw the nipple as deeply into the mouth as babies who were not tongue-tied.

Some babies with tongue and/or lip-tie may manage to nurse well enough to gain weight adequately in the early weeks, but they may not be able to maintain a full milk supply as they grow. Their restrictions will likely continue to affect the ease of breastfeeding. Feeds may be long and frequent–10-12 times a day or more. Often these babies do not nurse for comfort and may have difficulty managing solids when they are older.

Tongue and lip-ties affect more than breastfeeding. Even if a baby can breastfeed well and without causing pain, restrictive frenulums can affect jaw and dental development, breathing, chewing, swallowing and digestion. Tongue and/or lip ties are also associated with reflux, which can cause significant pain for baby and may result in the need for medication.

Any of the following symptoms in parent or baby may indicate that tongue-tie is affecting breastfeeding.

Signs in baby:
•poor latch and suck
•unusually strong suck due to baby using excess vacuum to remove milk
•clicking sound while nursing (poor suction)
•ineffective milk transfer
•infrequent swallowing after initial let-down
•inadequate weight gain or weight loss
•irritability or colic
•gas and reflux
•fussiness and frequent arching away from the breast
•fatigue within one to two minutes of beginning to nurse
•difficulty establishing suction to maintain a deep grasp on the breast
•breast tissue sliding in and out of baby’s mouth while feeding
•gradual sliding off the breast
•chewing or biting on the nipple
•falling asleep at the breast without taking in a full feed
•coughing, choking, gulping, or squeaking when feeding
•spilling milk during feeds
•jaw quivering after or between feeds

Assessing baby for tongue-tie: (baby may not have every sign)
•Does baby’s tongue rise less than half-way to the palate when crying?
•Do the sides of the tongue lift but not the center?
•Can you see a dip in the tongue in the center of the mouth?
•Does tongue have a heart shaped tip?
•Does baby have a high, narrow or bubble palate?
•Can you see or feel a tight frenulum?

To feel for a restrictive frenulum, you can use the “Murphy Maneuver,” developed by San-Diego pediatrician Dr. James Murphy. Put your little finger at the base of baby’s tongue and draw across the floor of the mouth. If you feel a resistance in the center of baby’s mouth, that is the frenulum. If you cannot get past this frenulum without going around it, then it may be restrictive enough to affect baby’s ability to breastfeed.

The following link shows a method for visualizing a restrictive frenulum that is difficult to see.

Lip-ties often accompany tongue-ties. If you lift your baby’s upper lip and see a frenulum that is tight and if the gums blanch (turn white) when the lip is lifted, your baby may have a lip-tie. The following two articles may help with assessing for lip-ties.

Cranio Sacral Therapy is a helpful intervention for babies with restrictive frenulums. CST is a light touch therapy that releases tight muscles and can improve baby’s ability to latch and breastfeed, but CST may need to be repeated frequently order to maintain its effectiveness. There are exercises that might help a baby to compensate for the restrictions and careful attention to latch and positioning, may also help the baby to breastfeed more effectively. None of these interventions enable the tongue-tied baby to have full mobility of the tongue and they are most effective when used along with release of restrictive frenulums, in order to normalize function. This procedure is performed with surgical scissors or laser and is called a frenotomy.

Many babies with restrictive frenulums cannot nurse effectively unless both tongue and lip-ties are revised by frenotomy. With an experienced provider, revision is quick and discomfort is minimal. The discomfort from a frenotomy varies from unnoticeable (some infants sleep through the procedure) to about the same amount of pain as a from a vaccination. The baby can nurse immediately afterward which also relieves pain.

If breastfeeding hurts the parent or if baby struggles to get enough milk, then the breastfeeding relationship is at risk. The risks of not breastfeeding outweigh the temporary discomfort of revision. If you are considering a tongue and/or lip-tie revision, it is important to find a provider who is very experienced in revising restrictive frenulums in infants and who is very familiar with how these restrictive frenulums affect breastfeeding. Experienced providers will know how to revise completely and without the need for general anesthesia.

The following is a link to a video of laser tongue-tie revision in a 14 year old. The doctor has made this available for anyone to view. The mom wanted to have this procedure done because her daughter had jaw tension, clenching and tooth grinding. She also breastfed poorly as an infant.